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Abstract
Importance: Prevention and management of cardiovascular disease in patients with type 2 diabetes (T2DM) and obesity remains a challenge.
Objective: To compare rates of mortality, coronary heart disease, cerebrovascular disease, and congestive failure associated with conventional medical management, bariatric surgery and novel diabetes therapeutics among adults with T2DM and obesity. Data Sources: PubMed/MEDLINE, Embase, and the Cochrane Library from database inception to July 20, 2020. Study Selection: Randomized controlled trials (RCTs) and observational studies that used robust adjustment for confounding comparing bariatric surgery (Roux-En-Y bypass or sleeve gastrectomy) to medical management and reported selected cardiovascular outcomes for at least 1 year of follow-up. Data Extraction and Synthesis: Two reviewers independently screened studies and extracted data. A Bayesian meta-analysis was performed to derive odds ratios (ORs) and 95% credible intervals (CrIs). To estimate absolute treatment benefits of bariatric surgery with those expected from GLP-1 receptor agonists and SGLT-2 inhibitors, we applied odds ratios to simulated patient-level Look AHEAD trial data reflecting conventional medical management and estimated 5-year cumulative incidence for each outcome and intervention. We performed bootstrapping for 95% uncertainty intervals (UIs).
Main Outcomes and Measures: All-cause mortality, coronary heart disease (myocardial infarction, unstable angina, percutaneous coronary intervention, or coronary artery bypass grafting), cerebrovascular disease (stroke, carotid stenting, or carotid endarterectomy), and congestive heart failure.
Results: A total of 23,144 bariatric surgery patients and 36,932 medically managed patients from 7 RCTs and 12 matched observational studies were included. Bariatric surgery was associated with significantly lower odds of all-cause mortality (OR, 0.34 [95% CrI 0.21–0.50]), coronary heart disease (OR, 0.46 [95% CrI 0.30–0.67]), cerebrovascular disease (OR, 0.48 [95% CrI 0.26–0.85]) and congestive heart failure (OR, 0.42 [95% CrI 0.23–0.78]). The odds of mortality associated with bariatric surgery remained significantly lower regardless of follow-up duration (1–5 years vs >5 years) or whether studies included or excluded patients with a history of cardiovascular disease. Effect estimates from the sub-group analyses of RCTs were uncertain. Compared to conventional medical management, bariatric surgery was associated with greatest absolute risk reduction (ARR [95% UI]) of all-cause mortality at 5-years (ARR, 1.6% [1.1–2.2%]), followed by SGLT-2 inhibitors (ARR, 0.6% [0.4–0.8%]), and GLP-1 receptor agonists (ARR, 0.3% [0.1–0.4%]). Absolute treatment benefits for cardiovascular outcomes at 5-years followed similar trends.
Conclusions and Relevance: Bariatric surgery may be associated with larger absolute treatment benefits for mortality, coronary heart disease, cerebrovascular disease, and congestive heart failure. The advent of GLP-1 receptor agonists and SGLT-2 inhibitors has changed the landscape of medical management for T2DM and there is an imperative need for randomized cardiovascular outcome trials comparing surgery with contemporary medical management strategies. Back to top
